Provider Demographics
NPI:1033205638
Name:MITCHELL, JERILYN J (CNS, LP (PMHCNS-BC,)
Entity type:Individual
Prefix:MRS
First Name:JERILYN
Middle Name:J
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:CNS, LP (PMHCNS-BC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 SOUTH CASCADE STREET
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2813
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-736-8757
Practice Address - Street 1:712 SOUTH CASCADE STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2813
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-736-8757
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR054697-5364S00000X
MNLP2805364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5457131-01OtherMA PROVIDER FOR CNS, LP
MN087-058700Medicaid
MNP06168Medicare UPIN
MN890000105Medicare ID - Type Unspecified